1
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Li J. 18F-AlF-NOTA-octreotide PET/CT in the localization of tumor-induced osteomalacia: case series and literature review. Front Endocrinol (Lausanne) 2024; 15:1400751. [PMID: 38887276 PMCID: PMC11180837 DOI: 10.3389/fendo.2024.1400751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/21/2024] [Indexed: 06/20/2024] Open
Abstract
Introduction This study explores tumor-induced osteomalacia (TIO) through a case series and literature review, assessing the diagnostic potential of 18F-AlF-NOTA-octreotide (18F-OC) positron emission tomography/computed tomography (PET/CT). Methods We analyzed TIO patients who underwent 18F-OC PET/CT. Parameters such as tumor dimension, the maximum standardized uptake value (SUVmax), the mean standardized uptake value (SUVmean) and metabolic tumor volume (MTV) were meticulously assessed. Clinical features and imaging characteristics pertinent to TIO were reviewed. Results 6 patients with clinical suspicion of TIO exhibited hypophosphatemia (0.25 to 0.64 mmol/L), elevated alkaline phosphatase (ALP) levels (142 to 506 U/L), and increased parathyroid hormone (PTH) levels (92.9 to 281.7 pg/mL). Of these patients, two underwent FGF-23 testing, with results of 3185.00 pg/ml and 17.56 pg/ml, respectively. Conventional imaging modalities depicted widespread osteoporosis, with several cases demonstrating fractures indicative of osteomalacic and associated pathological fractures. Subsequent 18F-OC PET/CT facilitated the accurate localization of causative tumors, with histopathological examination confirming the diagnosis of phosphaturic mesenchymal tumor (PMT). The interval from initial clinical presentation to definitive TIO diagnosis spanned approximately 2.5 years (range: 1 - 4 years), with tumors varying in size (maximum diameter: 7.8 to 40.0 mm), SUVmax (5.47 to 25.69), SUVmean (3.43 to 7.26), and MTV (1.27 to 18.59 cm3). Conclusion The implementation of whole-body 18F-OC PET/CT imaging emerges as a critical tool in the identification of occult tumors causing TIO. Future investigations incorporating a broader cohort are imperative to further delineate the diagnostic and therapeutic implications of 18F-OC PET/CT in managing TIO.
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Affiliation(s)
- Jing Li
- Department of Nuclear Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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2
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Liu S, Zhou X, Liu Y, Zhang J, Xia W. Preoperative evaluation and orthopedic surgical strategies for tumor-induced osteomalacia. J Bone Oncol 2024; 45:100600. [PMID: 38577550 PMCID: PMC10990903 DOI: 10.1016/j.jbo.2024.100600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
Tumor-induced osteomalacia (TIO), also known as oncogenic osteomalacia, is very rare, with about 1000 reported cases globally. Removing most TIO culprit tumors requires the evaluation and intervention of orthopedic doctors. However, orthopedic doctors often have a poor understanding of the optical treatment of TIO due to its rarity. In addition, most TIO patients lack specific clinical manifestations. Also, the clinical localization and qualitative diagnosis of TIO are difficult and thus can easily be misdiagnosed and mistreated. Furthermore, the true incidence rate of TIO may be underestimated. Although many breakthroughs have been made in exploring the pathogenesis, clinical diagnosis, and treatment of TIO, rational and standardized orthopedic surgical treatment experience summary and sorting for TIO patients are lacking. In this article, the recent experience and progress in the field of orthopedic surgical treatment for TIO globally have been summarized, providing a theoretical basis and new clinical practice guidance for the rational treatment of TIO patients.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jianguo Zhang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weibo Xia
- Department of Endocrinology, National Health Commission Key Laboratory of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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3
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Wong MT, Azadbakht J, Fadare O, Smitaman EE. Test yourself answer: plantar soft tissue foot mass with insufficiency-type stress fractures. Skeletal Radiol 2024; 53:595-596. [PMID: 37798375 DOI: 10.1007/s00256-023-04470-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/02/2023] [Accepted: 09/26/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Mitchell T Wong
- School of Medicine, the University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
| | | | - Oluwole Fadare
- Department of Pathology, Division of Anatomic Pathology, University of California San Diego, 9300 Campus Point Drive, Suite 1-200, La Jolla, CA, 92093, USA
| | - Edward Eddie Smitaman
- Department of Radiology, Division of Musculoskeletal Imaging, University of California San Diego, 408 Dickinson Street, Mail Code 8226, San Diego, CA, 92103, USA
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Sun X, Ni P, Xie T, Wu S. Phosphaturic Mesenchymal Tumor Along the Hallux side Inducing a Chronic non-Healing Wound: A Case Report with Literature Review. INT J LOW EXTR WOUND 2023; 22:779-787. [PMID: 35043721 DOI: 10.1177/15347346221074163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Phosphaturic mesenchymal tumor (PMT) is a rare paraneoplastic syndrome characterized by renal phosphate wasting, hypophosphatemia, and bone calcification disorders. Complete surgical resection of the tumor is believed to be the most effective treatment measure. However, the diagnosis of PMT is very difficult because of its insidious and small size, especially, when it appears in subcutaneous tissue with a chronic non-healing wound. We report a rare case of a 38-year-old man with a chronic non-healing wound on the left hallux for approximately eight months. Plain radiographic images and magnetic resonance imaging (MRI) revealed a cystic radiolucent shadow in the left distal phalanx. Bone scan observations also showed increased uptake in the same location. Histologically, this tumor was composed of numerous spindle cells with clusters of giant cells. The serum FGF23 level was significantly higher before surgery, with higher FGF23 levels closer to the tumor. Reverse transcription polymerase chain reaction and immunohistochemistry further confirmed the high expression of FGF23 in tumors. These data suggest that FGF23 may be a potential causative factor of PMT. The serum FGF23 levels might be useful for the diagnosis of PMT and localization of the tumor. The tumor was CD56- and D2 to 40-positive and CD31-negative. The non-healing wound caused by PMT might be attributed to the invasive growth of the tumor, destruction of intercellular junctions, and decrease in the number of endothelial cells.
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Affiliation(s)
- Xiaofang Sun
- The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Pengwen Ni
- Shanghai ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Xie
- Shanghai ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shaohan Wu
- The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
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5
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Helgebostad R, Revheim ME, Johnsrud K, Amlie K, Alavi A, Connelly JP. Clinical Applications of Somatostatin Receptor (Agonist) PET Tracers beyond Neuroendocrine Tumors. Diagnostics (Basel) 2022; 12:diagnostics12020528. [PMID: 35204618 PMCID: PMC8870812 DOI: 10.3390/diagnostics12020528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 11/17/2022] Open
Abstract
Somatostatin receptor (SSTR) agonist tracers used in nuclear medicine scans are classically used for neuroendocrine tumor diagnosis and staging. SSTR are however, expressed more widely in a variety of cells as seen in the distribution of physiological tracer uptake during whole body scans. This provides opportunities for using these tracers for applications other than NETs and meningiomas. In this qualitative systematic review, novel diagnostics in SSTR-PET imaging are reviewed. A total of 70 studies comprised of 543 patients were qualitatively reviewed. Sarcoidosis, atherosclerosis and phosphaturic mesenchymal tumors represent the most studied applications currently with promising results. Other applications remain in progress where there are many case reports but a relative dearth of cohort studies. [18F]FDG PET provides the main comparative method in many cases but represents a well-established general PET technique that may be difficult to replace, without prospective clinical studies.
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Affiliation(s)
- Rasmus Helgebostad
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Mona-Elisabeth Revheim
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
- Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kjersti Johnsrud
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Kristine Amlie
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA;
| | - James Patrick Connelly
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, P.O. Box 4956 Nydalen, 0424 Oslo, Norway; (R.H.); (M.-E.R.); (K.J.); (K.A.)
- Correspondence:
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Athonvarangkul D, Insogna KL. New Therapies for Hypophosphatemia-Related to FGF23 Excess. Calcif Tissue Int 2021; 108:143-157. [PMID: 32504139 DOI: 10.1007/s00223-020-00705-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022]
Abstract
FGF23 is a hormone produced by osteocytes in response to an elevation in the concentration of extracellular phosphate. Excess production of FGF23 by bone cells, or rarely by tumors, is the hormonal basis for several musculoskeletal syndromes characterized by hypophosphatemia due to renal phosphate wasting. FGF23-dependent chronic hypophosphatemia causes rickets and osteomalacia, as well as other skeletal complications. Genetic disorders of FGF23-mediated hypophosphatemia include X-linked hypophosphatemia (XLH), autosomal dominant hypophosphatemic rickets (ADHR), autosomal recessive hypophosphatemic rickets (ARHR), fibrous dysplasia of bone, McCune-Albright syndrome, and epidermal nevus syndrome (ENS), also known as cutaneous skeletal hypophosphatemia syndrome (CSHS). The principle acquired form of FGF23-mediated hypophosphatemia is tumor-induced osteomalacia (TIO). This review summarizes current knowledge about the pathophysiology and clinical presentation of the most common FGF23-mediated conditions, with a focus on new treatment modalities. For many decades, calcitriol and phosphate supplements were the mainstay of therapy. Recently, burosumab, a monoclonal blocking antibody to FGF23, has been approved for treatment of XLH in children and adults, and an active comparator trial in children has shown good efficacy and safety for this drug. The remainder of FGF23-mediated hypophosphatemic disorders continue to be treated with phosphate and calcitriol, although ongoing trials with burosumab for treatment of tumor-induced osteomalacia show early promise. Burosumab may be an effective treatment for the remainder of FGF23-mediated disorders, but clinical trials to support that possibility are at present not available.
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Affiliation(s)
- Diana Athonvarangkul
- Department of Medicine Section of Endocrinology, Yale School of Medicine, PO Box 802080, New Haven, CT, 06520, USA.
| | - Karl L Insogna
- Department of Medicine Section of Endocrinology, Yale School of Medicine, PO Box 802080, New Haven, CT, 06520, USA
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Krishnappa B, Jadhav SR, Lila AR, Bandgar TR. Tumour-induced osteomalacia due to an intra-abdominal mesenchymal tumour. BMJ Case Rep 2019; 12:12/12/e231728. [PMID: 31806630 DOI: 10.1136/bcr-2019-231728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 50-year-man presented with debilitating lower-limb proximal muscle weakness and hip pain since 3 years. Investigations (serum calcium (8.9 mg/dL), serum phosphorus (1.5 mg/dL), serum albumin (40 g/L), parathyroid hormone (116 pg/mL (12.30 pmol/L)), 25(OH)D3 (25.2 ng/mL (63 nmol/L)) 1,25(OH)2 D3 (19 pg/mL (45.60 pmol/L)), tubular reabsorption of phosphate of 0.22 and elevated serum fibroblast growth factor 23 (FGF23) (387.7 RU/mL)) were consistent with tumour-induced osteomalacia (TIO). Localisation studies (68Ga DOTATATE positron emission tomography (PET)/CT and 18FDG-PET/CT) did not reveal any lesion. Re-evaluation after 2 and 5 years with 68Ga-DOTANOC PET/CT showed 2×1.4 cm progressively increasing rounded soft tissue enhancing mass close to splenic hilum (SUV max: 26.4). Tumour was resected by laparotomy. Both FGF23 (120 RU/mL on day 3) and serum phosphorus (2.5 mg/dL on day 10) normalised with significant clinical improvement after surgery. Histopathology revealed phosphaturic mesenchymal tumour. Here, we report the first case of intra-abdominal mesenchymal tumour causing TIO diagnosed by serial functional imaging.
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Affiliation(s)
| | | | - Anurag R Lila
- Endocrinology, Seth GS Medical College, Mumbai, Maharashtra, India
| | - Tushar R Bandgar
- Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
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8
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Yang M, Doshi KB, Roarke MC, Nguyen BD. Molecular Imaging in Diagnosis of Tumor-induced Osteomalacia. Curr Probl Diagn Radiol 2019; 48:379-386. [DOI: 10.1067/j.cpradiol.2018.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/31/2018] [Accepted: 06/20/2018] [Indexed: 11/22/2022]
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9
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Tumor-induced osteomalacia – Current imaging modalities and a systematic approach for tumor localization. Clin Imaging 2019; 56:114-123. [DOI: 10.1016/j.clinimag.2019.04.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022]
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10
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Tumour-induced osteomalacia: A case report of craniofacial localization. OTOLARYNGOLOGY CASE REPORTS 2019. [DOI: 10.1016/j.xocr.2019.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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11
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John JR, Hephzibah J, Oommen R, Shanthly N, Mathew D. Ga-68 DOTATATE Positron Emission Tomography-Computed Tomography Imaging in Oncogenic Osteomalacia: Experience from a Tertiary Level Hospital in South India. Indian J Nucl Med 2019; 34:188-193. [PMID: 31293296 PMCID: PMC6593943 DOI: 10.4103/ijnm.ijnm_14_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aim Utility of Ga68 DOTATATE PETCT imaging to localise cause for oncogenic osteomalacia (OOM). Materials and Methods Retrospective analysis between March 2015 to March 2018 of all patients with a clinical diagnosis (based on a combination of clinical history, hypophosphatemia and elevated FGF-23 values) of OOM who underwent Ga-68 DOTATATE PET/CT. Results Total of 27 patients had undergone Ga-68 DOTATATE PET/CT imaging in our centre from March 2015 to March 2018. Of these 16 patients with clinically suspected oncogenic osteomalacia were included in our study. Age range 18-61 years of which 12 were males. Total of 13 (81.25%) patients were found to be positive on imaging for a possible mesenchymal tumour. Most common site of tumour was the lower limb (76%). Most common presenting symptom was bone pain (81%) followed by muscle weakness (19%). Overall, 10 patients underwent surgery, all of whose biopsy was reported as phosphaturic mesenchymal tumour. During the three month follow up, serum phosphorous measured in 15/16, post-surgical/ medical treatment had normalised in all except two patients who had undergone only medical therapy with neutral phosphate. Fall in FGF-23 was more pronounced in surgically treated patients as compared to those who received medical treatment. Conclusion Ga68-DOTATE PET/CT is a useful investigatory modality for localizing cause for oncogenic osteomalacia.
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Affiliation(s)
- Junita Rachel John
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Julie Hephzibah
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Regi Oommen
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nylla Shanthly
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - David Mathew
- Department of Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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12
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Imel EA, White KE. Pharmacological management of X-linked hypophosphataemia. Br J Clin Pharmacol 2018; 85:1188-1198. [PMID: 30207609 DOI: 10.1111/bcp.13763] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022] Open
Abstract
The most common heritable disorder of renal phosphate wasting, X-linked hypophosphataemia (XLH), was discovered to be caused by inactivating mutations in the phosphate regulating gene with homology to endopeptidases on the X-chromosome (PHEX) gene in 1995. Although the exact molecular mechanisms by which PHEX mutations cause disturbed phosphate handling in XLH remain unknown, focus for novel therapies has more recently been based upon the finding that the bone-produced phosphaturic hormone fibroblast growth factor-23 is elevated in XLH patient plasma. Previous treatment strategies for XLH were based upon phosphate repletion plus active vitamin D analogues, which are difficult to manage, fail to address the primary pathogenesis of the disease, and can have deleterious side effects. A novel therapy for XLH directly targeting fibroblast growth factor-23 via a humanized monoclonal antibody (burosumab-twza/CRYSVITA, henceforth referred to just as burosumab) has emerged as an effective, and recently approved, pharmacological treatment for both children and adults. This review will provide an overview of the clinical manifestations of XLH, the molecular pathophysiology, and summarize its current treatment.
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Affiliation(s)
- Erik A Imel
- Department of Medicine, Division of Endocrinology and Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Pediatrics, Section of Endocrinology and Diabetology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth E White
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
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Bech AP, Hoorn EJ, Zietse R, Wetzels JFM, Nijenhuis T. Yield of diagnostic tests in unexplained renal hypophosphatemia: a case series. BMC Nephrol 2018; 19:220. [PMID: 30180816 PMCID: PMC6123988 DOI: 10.1186/s12882-018-1017-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 08/27/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Isolated renal hypophosphatemia may be inherited or acquired. An increasing number of patients with unexplained renal hypophosphatemia is being referred to our clinics, but the optimal diagnostic work-up is not known. Therefore, the aim of this study was to assess the diagnostic yield in these patients. METHODS We retrospectively evaluated all patients who were referred because of unexplained isolated renal hypophosphatemia to two academic tertiary referral centers in The Netherlands in the period of 2013-2017. RESULTS We evaluated 17 patients. In five female patients renal hypophosphatemia could be attributed to the use of oral contraceptives. The other 12 patients had a median age of 48 years (10 males). There were no other signs of tubulopathy and none of the patients used drugs known to be associated with hypophosphatemia. FGF23 levels were above normal (> 125 RU/ml) in 2/12 patients. Genetic testing, performed in all patients, did not identify a mutation in genes known to be associated with renal phosphate wasting. A scan with a radiolabeled somatostatin analogue was performed in 8 patients. In one patient, with an FGF23 level of 110 RU/ml, an increased uptake of the somatostatin analog was observed due to tumor induced osteomalacia (TIO). CONCLUSIONS Oral contraceptive use is an important but under-recognized cause of renal hypophosphatemia. The cause of isolated renal hypophosphatemia remained unexplained in the majority of other patients despite extensive and expensive additional investigations. The pre-test probability for tumor-induced osteomalacia or inherited renal hypophosphatemia in a patient with aspecific complaints and a normal FGF23 level is low. Further research is needed to investigate which patients should be screened for TIO. At present we suggest to perform somatostatin scans only in patients with severe complaints, elevated FGF23 levels, or progressive disease.
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Affiliation(s)
- A P Bech
- Department of Nephrology, Radboud university medical center, Nijmegen, The Netherlands.
| | - E J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus medical center, Rotterdam, The Netherlands
| | - R Zietse
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus medical center, Rotterdam, The Netherlands
| | - J F M Wetzels
- Department of Nephrology, Radboud university medical center, Nijmegen, The Netherlands
| | - T Nijenhuis
- Department of Nephrology, Radboud university medical center, Nijmegen, The Netherlands
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Diagnostic performance and impact on patient management of 68Ga-DOTA-TOC PET/CT for detecting osteomalacia-associated tumours. Eur J Nucl Med Mol Imaging 2018. [PMID: 29532101 DOI: 10.1007/s00259-018-3971-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Oncogenic osteomalacia is an endocrine disorder induced by small benign tumours (TIO) producing excessive fibroblast growth factor-23 (FGF23). The only way of curing oncogenic osteomalacia is surgical resection of the culprit TIO, which is extremely difficult to detect using conventional imaging modalities due to its small size and variable location in the body. Since TIO frequently overexpress somatostatin receptors, a clinical utility of SPECT or PET with radiolabelled somatostatin analogues has been reported. Among them, 68Ga-DOTA-TOC has recently been granted a marketing authorization, facilitating its routine application. We report here the results of the first series evaluating the diagnostic performance of 68Ga-DOTA-TOC PET/CT in detecting TIO and its impact on patient management. METHODS 68Ga-DOTA-TOC PET/CT and clinical and imaging data from 15 patients with clinical and biochemical signs of oncogenic osteomalacia were retrospectively reviewed. The 68Ga-DOTA-TOC PET/CT findings were compared with the results of post-surgical pathology and clinical and biochemical follow-up. RESULTS 68Ga-DOTA-TOC PET/CT resulted in the detection of one focus suspicious for TIO in nine of 15 patients (60%), and a tumour was surgically removed in eight. Post-operative pathology confirmed a TIO in those eight patients whose symptoms diminished promptly and biochemical anomalies resolved. 68Ga-DOTA-TOC PET/CT sensitivity, specificity and accuracy were 73%, 67% and 71%, respectively. 68Ga-DOTA-TOC PET/CT findings affected patient management in 67% of cases. In particular, 68Ga-DOTA-TOC PET/CT was able to detect the TIO with a negative or a false-positive result of a previous 111In-pentetreotide SPECT/CT in 5/8 patients (63%) or a previous FDG PET/CT in 7/11 patients (64%). No close relationship was found between the positivity of 68Ga-DOTA-TOC PET/CT and the serum level of a biochemical marker. However, a true-positive result of 68Ga-DOTA-TOC PET/CT was obtained in only one patient with a non-elevated serum level of FGF23. CONCLUSION 68Ga-DOTA-TOC PET/CT is an accurate imaging modality in the detection of TIO; in particular, it is worthwhile after failure of somatostatin receptor SPECT(/CT) or FDG PET/CT.
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15
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Florenzano P, Gafni RI, Collins MT. Tumor-induced osteomalacia. Bone Rep 2017; 7:90-97. [PMID: 29021995 PMCID: PMC5633085 DOI: 10.1016/j.bonr.2017.09.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/07/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome clinically characterized by bone pain, fractures and muscle weakness. It is caused by tumoral overproduction of fibroblast growth factor 23 (FGF23) that acts primarily at the proximal renal tubule, decreasing phosphate reabsorption and 1α-hydroxylation of 25 hydroxyvitamin D, thus producing hypophosphatemia and osteomalacia. Lesions are typically small, benign mesenchymal tumors that may be found in bone or soft tissue, anywhere in the body. In up to 60% of these tumors, a fibronectin-1(FN1) and fibroblast growth factor receptor-1 (FGFR1) fusion gene has been identified that may serve as a tumoral driver. The diagnosis is established by the finding of acquired chronic hypophosphatemia due to isolated renal phosphate wasting with concomitant elevated or inappropriately normal blood levels of FGF23 and decreased or inappropriately normal 1,25-OH2-Vitamin D (1,25(OH)2D). Locating the tumor is critical, as complete removal is curative. For this purpose, a step-wise approach is recommended, starting with a thorough medical history and physical examination, followed by functional imaging. Suspicious lesions should be confirmed by anatomical imaging, and if needed, selective venous sampling with measurement of FGF23. If the tumor is not localized, or surgical resection is not possible, medical therapy with phosphate and active vitamin D is usually successful in healing the osteomalacia and reducing symptoms. However, compliance is often poor due to the frequent dosing regimen and side effects. Furthermore, careful monitoring is needed to avoid complications such us secondary/tertiary hyperparathyroidism, hypercalciuria, and nephrocalcinosis. Novel therapeutical approaches are being developed for TIO patients, such as image-guided tumor ablation and medical treatment with the anti-FGF23 monoclonal antibody KRN23 or anti FGFR medications. The case of a patient with TIO is presented to illustrate the importance of adequate and appropriate evaluation of patients with bone pain and hypophosphatemia, as well as an step-wise localization study of patients with suspected TIO.
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Key Words
- 1,25-OH2-vitamin D, 1,25(OH)2D
- CT, computerized tomography
- FDG-PET/CT, fluorodeoxyglucose positron emission tomography with computerized tomography
- FGF1, fibroblast growth factor 1
- FGF23
- FGF23, fibroblast growth factor 23
- FGFR1, fibroblast growth factor receptor-1
- FISH, fluorescence in situ hybridization
- FN1, fibronectin-1
- MAPK, mitogen-activated protein kinase
- MRI, magnetic resonance imaging
- PMT, phosphaturic mesenchymal tumor
- PTH, parathyroid hormone
- Phosphaturic mesenchymal tumors
- SPECT, single-photon emission computed tomography
- TIO, tumor-induced osteomalacia
- TRP, tubular reabsorption of phosphate
- TmP/GFR, tubular maximum reabsorption of phosphate to glomerular filtration rate
- Tumor-induced osteomalacia
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Affiliation(s)
- Pablo Florenzano
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA.,Endocrinology Department, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rachel I Gafni
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Michael T Collins
- Section on Skeletal Disorders and Mineral Homeostasis, National Institutes of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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Clinkenbeard EL, White KE. Heritable and acquired disorders of phosphate metabolism: Etiologies involving FGF23 and current therapeutics. Bone 2017; 102:31-39. [PMID: 28159712 PMCID: PMC5537045 DOI: 10.1016/j.bone.2017.01.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 01/20/2017] [Accepted: 01/29/2017] [Indexed: 10/20/2022]
Abstract
Phosphate is critical for many cellular processes and structural functions, including as a key molecule for nucleic acid synthesis and energy metabolism, as well as hydroxyapatite formation in bone. Therefore it is critical to maintain tight regulation of systemic phosphate levels. Based upon its broad biological importance, disruption of normal phosphate homeostasis has detrimental effects on skeletal integrity and overall health. Investigating heritable diseases of altered phosphate metabolism has led to key discoveries underlying the regulation and systemic actions of the phosphaturic hormone Fibroblast growth factor-23 (FGF23). Both molecular and clinical studies have revealed novel targets for the development and optimization of therapies for disorders of phosphate handling. This review will focus upon the bridge between genetic discoveries involving disorders of altered FGF23 bioactivity, as well as describe how these findings have translated into pharmacologic application.
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Affiliation(s)
- Erica L Clinkenbeard
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth E White
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA.
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González G, Baudrand R, Sepúlveda MF, Vucetich N, Guarda FJ, Villanueva P, Contreras O, Villa A, Salech F, Toro L, Michea L, Florenzano P. Tumor-induced osteomalacia: experience from a South American academic center. Osteoporos Int 2017; 28:2187-2193. [PMID: 28341900 DOI: 10.1007/s00198-017-4007-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/10/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED The majority of tumor-induced osteomalacia cases have been reported in the Northern Hemisphere and Asia. In this first series of South American patients, we show that the clinical presentation and sensitivity of plasmatic fibroblast growth factor 23 and somatostatin analog-based imaging are similar to those described in other populations. INTRODUCTION Describe the experience of clinical presentation, diagnostic study, and treatment of patients with tumor-induced osteomalacia (TIO) in a South American academic center in comparison to literature. METHODS Analysis of the records of patients diagnosed with TIO. The clinical presentation, diagnostic studies, and treatment were analyzed. Fibroblast growth factor 23 (FGF23) was measured by ELISA. RESULTS Six patients were diagnosed with TIO during the studied period. The patients' median age was 53 years (range 22-64). All patients presented with weakness and pain in the extremities. Four experienced fractures during their evolution. The median time to diagnosis was 4.5 years (1-20). Biochemical studies showed hypophosphatemia, median of 1.4 mg/dL (1.2-1.6), with low maximum rates of tubular reabsorption of phosphate adjusted for glomerular filtration rate. FGF23 was elevated in 4/6 patients and inappropriately normal in the other two. In three patients, the location of the tumor was clinically evident and confirmed with anatomical imaging. In the remaining patients, two tumors were located with 68Ga DOTATATE-PET/CT and one with OctreoScan. The causal tumors were located in the lower extremities in five patients and invading the frontal sinus in one patient. In all patients, tumors were successfully removed. Within 14 days, there was normalization of phosphate and FGF23 levels and resolution of clinical symptoms in all patients. In all cases, the histopathology was compatible with a phosphaturic mesenchymal tumor. CONCLUSIONS The clinical presentation, delay time to diagnosis, FGF23 diagnostic sensitivity and histopathology in this first series of South American patients is similar to those described in other populations. The success of localization by somatostatin analog-based imaging, suggests this may the optimal imaging modality.
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Affiliation(s)
- G González
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - R Baudrand
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - M F Sepúlveda
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - N Vucetich
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - F J Guarda
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile
| | - P Villanueva
- Departamento de Neurocirugía, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - O Contreras
- Departamento de Radiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - A Villa
- Departamento de Traumatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile
| | - F Salech
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Centro de Investigacion Clinica Avanzada, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - L Toro
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Centro de Investigacion Clinica Avanzada, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - L Michea
- Instituto de Ciencias Biomédicas, Hospital Clinico Universidad de Chile, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - P Florenzano
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Cuarto piso, Santiago, Chile.
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Singh D, Chopra A, Ravina M, Kongara S, Bhatia E, Kumar N, Gupta S, Yadav S, Dabadghao P, Yadav R, Dube V, Kumar U, Dixit M, Gambhir S. Oncogenic osteomalacia: role of Ga-68 DOTANOC PET/CT scan in identifying the culprit lesion and its management. Br J Radiol 2017; 90:20160811. [PMID: 28181822 DOI: 10.1259/bjr.20160811] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the role of 68Ga-DOTANOC positron emission tomography (PET)/CT scan in localization of culprit lesion for biopsy and required intervention [surgical excision/radiofrequency ablation (RFA)] in patients with long-standing oncogenic osteomalacia (OOM)/tumour-induced osteomalacia. METHODS 17 patients (8 males and 9 females) underwent 68Ga-DOTANOC PET/CT scan. The patients referred with clinical and biochemical evidence of hypophosphatemia and raised fibroblast growth factor-23. Qualitative and semi-quantitative parameters were used to identify culprit lesions. RESULTS 68Ga-DOTANOC PET/CT scan revealed 52 lesions in 17 patients, and 37/52 of these lesions were tracer avid. 26/37 lesions were non-specific focal tracer-avid skeletal lesions (fractures or degenerative changes). 11/37 tracer-avid skeletal lesions present in 9 patients (3 lesions in 1 patient and 1 each in rest of the 8 patients) were highly suspicious for culprit lesions in view of high maximum standardized uptake value (SUVmax) (range 1.5-15.4; mean 7.0 ± 4.6), lesion size (0.9-5.0 cm; mean 3.3 ± 1.5) and associated soft-tissue component. During subsequent imaging with CT/MRI, 7/9 patients showed concordant lesions which were excised or biopsied and histopathologically verified as phosphaturic mesenchymal tumours. Surgical excision was resorted to in most of the detected lesions, and RFA was performed in one patient. CONCLUSION There is some overlap in SUVmax between fracture-/bone-associated lesions and culprit lesions with a tendency of most non-culprit lesions to have lower SUVmax and no associated soft-tissue component. In such scenario, intensely tracer-avid, larger non-fracture lesions with soft-tissue component may lead to identification of culprit lesion among multiple lesions. Following detection of culprit lesion, surgical removal is the best treatment. RFA is alternative to surgery in cases where surgery is not possible owing to osteopenia/poor bone health. Advances in knowledge: The main challenge in patients of long-standing OOM is the presence of multiple skeletal lesions (both tumour- or tracer-avid fractures), and it is confusing to identify culprit lesion. This was noted in our study with 68Ga-DOTANOC and has not been mentioned in studies performed with 68Ga-DOTATATE/TOC PET/CT. In such scenario, 68Ga-DOTANOC PET/CT needs to be reviewed and read thoroughly to localize the culprit lesion out of the multiple tracer-avid lesions.
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Affiliation(s)
- Deepa Singh
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Aditi Chopra
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India
| | | | - Srikant Kongara
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India.,3 Endolife Hospital, Guntur, Andhra Pradesh, India
| | - Eesh Bhatia
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India
| | - Narvesh Kumar
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Sushil Gupta
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India
| | - Subhash Yadav
- 2 Department of Endocrinology, SGPGIMS, Lucknow, India
| | | | | | - Veeresh Dube
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Utham Kumar
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Manish Dixit
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
| | - Sanjay Gambhir
- 1 Department of Nuclear Medicine, SGPGIMS, Lucknow, India
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El-Maouche D, Sadowski SM, Papadakis GZ, Guthrie L, Cottle-Delisle C, Merkel R, Millo C, Chen CC, Kebebew E, Collins MT. 68Ga-DOTATATE for Tumor Localization in Tumor-Induced Osteomalacia. J Clin Endocrinol Metab 2016; 101:3575-3581. [PMID: 27533306 PMCID: PMC5052344 DOI: 10.1210/jc.2016-2052] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Phosphaturic mesenchymal tumors (PMTs) are small, typically difficult to localize, and express somatostatin receptors. Recent work suggests imaging studies using 68Gallium (68Ga)-conjugated somatostatin peptide analogues, such as 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)TATE, which enables somatostatin receptor imaging with positron emission tomography (PET), may be useful at identifying these tumors. OBJECTIVE Our objective was to evaluate the use of 68Ga-DOTATATE PET/computed tomography (CT) for tumor localization in tumor-induced osteomalacia (TIO). DESIGN This was a single-center prospective study of patients with TIO. SETTING The study was conducted at the National Institutes of Health Clinical Center between February 2014 and February 2015. SUBJECTS Eleven subjects (six females, five males) with TIO were included. INTERVENTION Subjects underwent 68Ga-DOTATATE PET/CT in addition to 111In-pentetreotide single-photon emission CT (Octreoscan- SPECT/CT) and fluorodeoxyglucose-PET/CT (18F FDG-PET/CT) scan. MAIN OUTCOME MEASURES Localization of PMTs on the previously described imaging modalities were determined. RESULTS The tumor was successfully localized in 6/11 (54.5%) subjects (one was metastatic). The tumor was identified by 68Ga-DOTATATE in all six cases. Both Octreoscan-SPECT/CT and 18F FDG-PET each identified the tumor in 4/6. In no cases was 68Ga-DOTATATE the only imaging study to identify the tumor. CONCLUSIONS In this first prospective study comparing 68Ga-DOTATATE PET/CT to Octreoscan-SPECT/CT and 18F FDG-PET in TIO localization, 68Ga-DOTATATE PET/CT demonstrated the greatest sensitivity and specificity, suggesting that it may be the best single study for localization of PMTs in TIO.
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Affiliation(s)
- Diala El-Maouche
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Samira M Sadowski
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Georgios Z Papadakis
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Lori Guthrie
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Candice Cottle-Delisle
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Roxanne Merkel
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Corina Millo
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Clara C Chen
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Electron Kebebew
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Michael T Collins
- Division of Endocrinology (D.E.-M.), Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Skeletal Clinical Studies Unit (D.E.-M., L.G., M.T.C.), Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; Thoracic and Endocrine Surgery (S.M.S.), University Hospitals of Geneva, Geneva, Switzerland; The Endocrine Oncology Branch (S.M.S., C.C.-D., R.M., E.K.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Positron Emission Tomography Department (G.Z.P., C.M.), Warren Grant Magnusson Clinical Center, National Institutes of Health, Bethesda, Maryland; Nuclear Medicine Division (C.C.C.), Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland
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Alonso G, Varsavsky M. Osteomalacia tumoral: un síndrome paraneoplásico emergente. ACTA ACUST UNITED AC 2016; 63:181-6. [DOI: 10.1016/j.endonu.2015.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 10/22/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
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Comparison of 18F-FDG and 68Ga DOTATATE PET/CT in localization of tumor causing oncogenic osteomalacia. Clin Nucl Med 2015; 40:e6-e10. [PMID: 24999675 DOI: 10.1097/rlu.0000000000000460] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome, usually caused by small benign mesenchymal tumors. The localization of these tumors is challenging, however, essential for the management. We compared the utility of F-FDG PET/CT and Ga DOTATATE PET/CT to detect the site of primary tumor in patients with suspicion of TIO. PATIENTS AND METHODS Retrospective analysis of 6 patients with hypophosphatemic osteomalacia and suspicion of TIO was performed. Ga DOTATATE PET/CT study was performed in all 6 patients to localize the tumor. F-FDG PET/CT was performed in 4 of 6 patients. F-FDG and Ga DOTATATE PET/CT studies were performed within 1 week of each other. Both studies were interpreted blindly without the knowledge of other imaging findings. RESULTS All patients had symptoms of osteomalacia and hypophosphatemia. All except 1 patient had increased level of fibroblast growth factor 23. The lag time (symptoms to PET diagnosis) ranged from 1.5 to 22 years. In 4 patients, where both studies were performed, F-FDG and Ga DOTATATE PET/CT were able to localize the tumor in 2 and 3 patients. Ga DOTATATE PET/CT detected tumor in 5 (83.3%) of 6 patients. CONCLUSIONS Ga DOTATATE PET/CT performed better than F-FDG PET/CT and is useful in the detection of tumors causing oncogenic osteomalacia. Therefore, in clinically suspected cases of hypophosphatemic osteomalacia, Ga DOTATATE PET/CT may be performed as first-line imaging investigation to avoid delay in the treatment of this devastating but curable disease. However, further studies with large patient population are warranted to validate our data.
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Zhang J, Zhu Z, Zhong D, Dang Y, Xing H, Du Y, Jing H, Qiao Z, Xing X, Zhuang H, Li F. 68Ga DOTATATE PET/CT is an Accurate Imaging Modality in the Detection of Culprit Tumors Causing Osteomalacia. Clin Nucl Med 2015; 40:642-646. [PMID: 26053726 DOI: 10.1097/rlu.0000000000000854] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Tumor-induced osteomalacia (TIO) is generally caused by small benign mesenchymal tumors producing fibroblast growth factor-23 (FGF-23). The only curative therapy of the disease is resection of the causative tumors. However, these tumors are extremely difficult to detect using conventional imaging modalities. This research was undertaken to evaluate efficacy of (68)Ga DOTATATE PET/CT in this clinical setting. METHODS Images of (68)Ga DOTATATE PET/CT and clinical charts from 54 patients with clinically suspected TIO were retrospectively reviewed. The image findings were compared with the results of histopathological examinations and clinical follow-ups. RESULTS (68)Ga DOTATATE PET/CT scans were positive in 44 patients, among which, 33 had surgery to remove the lesions. Postsurgical pathological examination confirmed causative tumors in 32 patients whose symptoms diminished promptly, and the serum phosphate levels became normal, which confirmed the diagnoses of TIO. Eleven patients with positive (68)Ga DOTATATE PET/CT did not have surgery. These 11 patients continued to have symptoms and hypophosphatemia but were not included in the final analysis because of lack of evidence to confirm or exclude TIO. Ten patients had negative (68)Ga DOTATATE PET/CT scans. All of these10 patients responded to conservative therapy and had normal serum phosphate levels in the follow-up, which excluded TIO. Therefore, the (68)Ga DOTATATE PET/CT imaging had a sensitivity of 100% (32/32) and a specificity of 90.9% (10/11). The overall accuracy of (68)Ga DOTATATE PET/CT scan in the detection of tumors responsible for osteomalacia is 97.7% (42/43). CONCLUSIONS (68)Ga DOTATATE PET/CT scan is an accurate imaging modality in the detection of tumors causing TIO.
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Affiliation(s)
- Jingjing Zhang
- From the *Departments of Nuclear Medicine, †Department of Pathology, ‡Department of Endocrinology Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; and §Department of Radiology, The Children's Hospital of Philadelphia University of Pennsylvania Perelman School of Medicine Philadelphia, PA
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Wang H, Zhong D, Liu Y, Jiang Y, Qiu G, Weng X, Xing X, Li M, Meng X, Li F, Zhu Z, Yu W, Xia W, Jin J. Surgical Treatments of Tumor-Induced Osteomalacia Lesions in Long Bones: Seventeen Cases with More Than One Year of Follow-up. J Bone Joint Surg Am 2015; 97:1084-94. [PMID: 26135075 DOI: 10.2106/jbjs.n.01299] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tumor-induced osteomalacia is a rare and fascinating paraneoplastic syndrome usually caused by a small, benign phosphaturic mesenchymal tumor. Most tumors are treated surgically, but we are unaware of any reports that compare the results of curettage and segmental resection for lesions in long bones. METHODS Seventeen patients (ten male and seven female) with tumor-induced osteomalacia lesions in long bones, who underwent surgical treatment from December 2004 to August 2013 in our hospital, were included in this retrospective study. The mean follow-up (and standard deviation) was 35 ± 27 months (range, twelve to 116 months). The characteristics of the tumor and the effects of different surgical treatments (curettage compared with segmental resection) were evaluated. RESULTS All patients showed typical clinical characteristics of tumor-induced osteomalacia, including elevated serum fibroblast growth factor-23 (FGF-23); 82% of tumors were in the epiphysis, and 82% grew eccentrically. The mean maximum diameter of the tumors was 2.4 ± 2.0 cm. The complete resection rates were similar for curettage (67%) and segmental resection (80%). However, the recurrence rate after curettage (50%) was higher than that after segmental resection (0%). The complete resection rate for secondary segmental resection (75%) was not different from that for primary segmental resection (83%). All of our cases of tumor-induced osteomalacia were caused by phosphaturic mesenchymal tumors. After successful removal of tumors, serum FGF-23 returned to normal within twenty-four hours and serum phosphorus levels returned to normal at a mean of 6.5 ± 3.5 days. CONCLUSIONS Most lesions in long bones are located in the epiphysis, so curettage is first suggested to maintain joint function. If curettage is incomplete or there is a recurrence, secondary segmental resection should be considered curative. Changes of serum FGF-23 and phosphorus levels before and after the operation may be of prognostic help.
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Affiliation(s)
- Hai Wang
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Dingrong Zhong
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Yong Liu
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Yan Jiang
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Guixing Qiu
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Xisheng Weng
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Xiaoping Xing
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Mei Li
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Xunwu Meng
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Fang Li
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Zhaohui Zhu
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Wei Yu
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Weibo Xia
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
| | - Jin Jin
- Departments of Orthopaedic Surgery (H.W., Y.L., G.Q., X.W., and J.J.), Endocrinology (Y.J., X.X., M.L., X.M., and W.X.), Pathology (D.Z.), Nuclear Medicine (F.L. and Z.Z.), and Radiology (W.Y.), Peking Union Medical College Hospital (PUMCH), Number 1 Shuaifuyuan hutong, Beijing 100730, People's Republic of China. E-mail address for H. Wang: . E-mail address for D. Zhong: . E-mail address for Y. Liu: . E-mail address for Y. Jiang: E-mail address for G. Qiu: . E-mail address for X. Weng: . E-mail address for X. Xing: . E-mail address for M. Li: . E-mail address for X. Meng: . E-mail address for F. Li: . E-mail address for Z. Zhu: . E-mail address for W. Yu: . E-mail address for W. Xia: . E-mail address for J. Jin:
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Meng T, Zhou W, Li B, Yin H, Li Z, Zhou L, Kong J, Yan W, Yang X, Liu T, Song D, Xiao J. En bloc resection for treatment of tumor-induced osteomalacia: a case presentation and a systematic review. World J Surg Oncol 2015; 13:176. [PMID: 25951872 PMCID: PMC4434570 DOI: 10.1186/s12957-015-0589-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 04/24/2015] [Indexed: 11/17/2022] Open
Abstract
Background Tumor-induced osteomalacia (TIO) is a rare disorder, which is commonly found in craniofacial locations and in the extremities. To the best of our knowledge, only 16 cases have been described in the spine, and this is the first report to describe a case of patient with TIO in the thoracic spine combined with a mesenchymal hamartoma which had confused the therapeutic strategies to date. Case description We report the case of a 60-year-old patient with hypophosphatemia and presented with limb weakness. Treating with phosphate did not correct the hypophosphatemia and an 111In pentetreotide scintigraphy (octreotide scan) revealed an increased uptake at the right forearm. The tumor was resected totally, and the histopathology revealed a mesenchymal hamartoma, but we noticed that hypophosphatemia was not corrected after the tumor resection. Then a whole-body magnetic resonance imaging (WB-MRI) was performed and the results revealed tumorous tissues at the right T1 vertebral pedicle. The tumor was removed with an en bloc method, and the pathology showed phosphaturic mesenchymal tumor. Follow-up at 1 year after surgery revealed no recurrence, and the serum phosphorus level of the patient was normal. Conclusions Tumor-induced osteomalacia is exceedingly rare with only 16 cases in spine published in the literature. It is difficult to find and leads to years of suffering debilitating complications. In this regard, the WB-MRI is a better method to locate the real tumor. Treating with phosphate can only relieve symptoms, and a complete surgical removal remains the gold standard treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12957-015-0589-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tong Meng
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Wang Zhou
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Bo Li
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Huabin Yin
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Zhenxi Li
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Lei Zhou
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Jinhai Kong
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Wangjun Yan
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Xinghai Yang
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Tielong Liu
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Dianwen Song
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
| | - Jianru Xiao
- Department of Bone Tumor Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, China.
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25
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Ho CL. Ga68-DOTA Peptide PET/CT to Detect Occult Mesenchymal Tumor-Inducing Osteomalacia: A Case Series of Three Patients. Nucl Med Mol Imaging 2015; 49:231-6. [PMID: 26279697 DOI: 10.1007/s13139-015-0328-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 02/14/2015] [Accepted: 02/17/2015] [Indexed: 10/23/2022] Open
Abstract
Tumor-induced osteomalacia (TIO) is a rare disease that manifests with paraneoplasic syndrome and overproduction of fibroblast growth factor 23 (FGF23), leading to renal phosphate wasting and hyperphosphaturia, eventually leading to acquired hypophosphatemic osteomalacia. Diagnosis of this disease is often challenging because of the small size of the lesion, which can be localized in bone or soft tissue anywhere in the body. Detecting these occult mesenchymal tumors (OMT) is of great importance as they are potentially curable after tumor resection. The purpose of this case series is to provide some insight into the diagnosis and localization of OMT associated with osteomalacia, particularly using functional imaging with Ga68-DOTA peptide PET/CT scans.
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Affiliation(s)
- Chi Long Ho
- Department of Diagnostic Radiology, Singapore General Hospital, 4 Outram Road, Singapore, 169608 Singapore
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26
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Breer S, Brunkhorst T, Beil FT, Peldschus K, Heiland M, Klutmann S, Barvencik F, Zustin J, Gratz KF, Amling M. 68Ga DOTA-TATE PET/CT allows tumor localization in patients with tumor-induced osteomalacia but negative 111In-octreotide SPECT/CT. Bone 2014; 64:222-7. [PMID: 24769333 DOI: 10.1016/j.bone.2014.04.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 03/27/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Abstract
Tumor-induced osteomalacia (TIO) is a paraneoplastic syndrome characterized by renal phosphate wasting, hypophosphatemia and low calcitriol levels as well as clinical symptoms like diffuse bone and muscle pain, fatigue fractures or increased fracture risk. Conventional imaging methods, however, often fail to detect the small tumors. Lately, tumor localization clearly improved by somatostatin-receptor (SSTR) imaging, such as octreotide scintigraphy or octreotide SPECT/CT. However, recent studies revealed that still a large number of tumors remained undetected by octreotide imaging. Hence, studies focused on different SSTR imaging methods such as 68Ga DOTA-NOC, 68Ga DOTA-TOC and 68Ga DOTA-TATE PET/CT with promising first results. Studies comparing different SSTR imaging methods for tumor localization in TIO are rare and thus little is known about diagnostic alternatives once a particular method failed to detect a tumor in patients with TIO. Here, we report the data of 5 consecutive patients suffering from TIO, who underwent both 111Indium-octreotide scintigraphy (111In-OCT) SPECT/CT as well as 68Ga DOTA-TATE PET/CT for tumor detection. While 111In-OCT SPECT/CT allowed tumor detection in only 1 of 5 patients, 68Ga DOTA-TATE PET/CT was able to localize the tumor in all patients. Afterwards, anatomical imaging of the region of interest was performed with CT and MRI. Thus, successful surgical resection of the tumor was achieved in all patients. Serum phosphate levels returned to normal and all patients reported relief of symptoms within weeks. Moreover, an iliac crest biopsy was obtained from every patient and revealed marked osteomalacia in all cases. Follow-up DXA revealed an increase in BMD of up to 34.5% 1-year postoperative, indicating remineralization. No recurrence was observed. In conclusion our data indicates that 68Ga DOTA-TATE PET/CT is an effective and promising diagnostic tool in the diagnosis of TIO, even in patients in whom 111In-OCT prior failed to detect a tumor.
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Affiliation(s)
- Stefan Breer
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Germany
| | | | - F Timo Beil
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Germany
| | - Kersten Peldschus
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Max Heiland
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Germany
| | - Susanne Klutmann
- Department of Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Germany
| | - Jozef Zustin
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Germany
| | | | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Germany.
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27
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Jing H, Li F, Zhuang H, Wang Z, Tian J, Xing X, Jin J, Zhong D, Zhang J. Effective detection of the tumors causing osteomalacia using [Tc-99m]-HYNIC-octreotide (99mTc-HYNIC-TOC) whole body scan. Eur J Radiol 2013; 82:2028-34. [DOI: 10.1016/j.ejrad.2013.04.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 04/17/2013] [Indexed: 10/26/2022]
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28
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Dezfulian M, Wohlgenannt O. Revision hip arthroplasty following recurrence of a phosphaturic mesenchymal tumor. J Surg Case Rep 2013; 2013:rjt059. [PMID: 24963901 PMCID: PMC3813727 DOI: 10.1093/jscr/rjt059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We report the case of a recurrent phosphaturic mesenchymal tumor (PHT) of the right acetabulum in a 47-year-old man with a long history of hip pain. After primary excision of the PHT, successful remission was expected due to normal phosphate levels. Over a long period, a recurrence led to destruction of the acetabulum and loosening of the back plate of the hip prosthesis. One-year follow-up after revision arthroplasty revealed normal phosphate levels, and the patient reported no complaints.
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Affiliation(s)
- Markus Dezfulian
- Department of Orthopedic Surgery, University Teaching Hospital, Medical University of Innsbruck, Feldkirch, Austria
| | - Othmar Wohlgenannt
- Department of Orthopedic Surgery, University Teaching Hospital, Medical University of Innsbruck, Feldkirch, Austria
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29
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Huang X, Jiang Y, Xia W. FGF23 and Phosphate Wasting Disorders. Bone Res 2013; 1:120-32. [PMID: 26273497 DOI: 10.4248/br201302002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 04/25/2013] [Indexed: 11/10/2022] Open
Abstract
A decade ago, only two hormones, parathyroid hormone and 1,25(OH)2D, were widely recognized to directly affect phosphate homeostasis. Since the discovery of fibroblast growth factor 23 (FGF23) in 2000 (1), our understanding of the mechanisms of phosphate homeostasis and of bone mineralization has grown exponentially. FGF23 is the link between intestine, bone, and kidney together in phosphate regulation. However, we still do not know the complex mechanism of phosphate homeostasis and bone mineralization. The physiological role of FGF23 is to regulate serum phosphate. Secreted mainly by osteocytes and osteoblasts in the skeleton (2,3), it modulates kidney handling of phosphate reabsorption and calcitriol production. Genetic and acquired abnormalities in FGF23 structure and metabolism cause conditions of either hyper-FGF23 or hypo-FGF23. Hyper-FGF23 is related to hypophosphatemia, while hypo-FGF23 is related to hyperphosphatemia. Both hyper-FGF23 and hypo-FGF23 are detrimental to humans. In this review, we will discuss the pathophysiology of FGF23 and hyper-FGF23 related renal phosphate wasting disorders (4).
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Affiliation(s)
- Xianglan Huang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Shuaifuyuan No. 1, Wangfujing, Dongcheng District, Beijing 100730, China
| | - Yan Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Shuaifuyuan No. 1, Wangfujing, Dongcheng District, Beijing 100730, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences , Shuaifuyuan No. 1, Wangfujing, Dongcheng District, Beijing 100730, China
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30
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Chong WH, Andreopoulou P, Chen CC, Reynolds J, Guthrie L, Kelly M, Gafni RI, Bhattacharyya N, Boyce AM, El-Maouche D, Crespo DO, Sherry R, Chang R, Wodajo FM, Kletter GB, Dwyer A, Collins MT. Tumor localization and biochemical response to cure in tumor-induced osteomalacia. J Bone Miner Res 2013; 28:1386-98. [PMID: 23362135 PMCID: PMC3900247 DOI: 10.1002/jbmr.1881] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 01/10/2013] [Accepted: 01/17/2013] [Indexed: 01/17/2023]
Abstract
Tumor-induced osteomalacia (TIO) is a rare disorder of phosphate wasting due to fibroblast growth factor-23 (FGF23)-secreting tumors that are often difficult to locate. We present a systematic approach to tumor localization and postoperative biochemical changes in 31 subjects with TIO. All had failed either initial localization, or relocalization (in case of recurrence or metastases) at outside institutions. Functional imaging with ¹¹¹Indium-octreotide with single photon emission computed tomography (octreo-SPECT or SPECT/CT), and ¹⁸fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) were performed, followed by anatomic imaging (CT, MRI). Selective venous sampling (VS) was performed when multiple suspicious lesions were identified or high surgical risk was a concern. Tumors were localized in 20 of 31 subjects (64.5%). Nineteen of 20 subjects underwent octreo-SPECT imaging, and 16 of 20 FDG-PET/CT imaging. Eighteen of 19 (95%) were positive on octreo-SPECT, and 14 of 16 (88%) on FDG-PET/CT. Twelve of 20 subjects underwent VS; 10 of 12 (83%) were positive. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were as follows: sensitivity = 0.95, specificity = 0.64, PPV = 0.82, and NPV = 0.88 for octreo-SPECT; sensitivity = 0.88, specificity = 0.36, PPV = 0.62, and NPV = 0.50 for FDG-PET/CT. Fifteen subjects had their tumor resected at our institution, and were disease-free at last follow-up. Serum phosphorus returned to normal in all subjects within 1 to 5 days. In 10 subjects who were followed for at least 7 days postoperatively, intact FGF23 (iFGF23) decreased to near undetectable within hours and returned to the normal range within 5 days. C-terminal FGF23 (cFGF23) decreased immediately but remained elevated, yielding a markedly elevated cFGF23/iFGF23 ratio. Serum 1,25-dihydroxyvitamin D₃ (1,25D) rose and exceeded the normal range. In this systematic approach to tumor localization in TIO, octreo-SPECT was more sensitive and specific, but in many cases FDG-PET/CT was complementary. VS can discriminate between multiple suspicious lesions and increase certainty prior to surgery. Sustained elevations in cFGF23 and 1,25D were observed, suggesting novel regulation of FGF23 processing and 1,25D generation.
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Affiliation(s)
- William H Chong
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Disease Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
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Clifton-Bligh RJ, Hofman MS, Duncan E, Sim IW, Darnell D, Clarkson A, Wong T, Walsh JP, Gill AJ, Ebeling PR, Hicks RJ. Improving diagnosis of tumor-induced osteomalacia with Gallium-68 DOTATATE PET/CT. J Clin Endocrinol Metab 2013; 98:687-94. [PMID: 23295468 DOI: 10.1210/jc.2012-3642] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
CONTEXT Tumor-induced osteomalacia (TIO) is a rarely diagnosed disorder presenting with bone pain, fractures, muscle weakness, and moderate-to-severe hypophosphatemia resulting from fibroblast growth factor 23-mediated renal phosphate wasting. Tumors secreting fibroblast growth factor 23 are often small and difficult to find with conventional imaging. OBJECTIVE We studied the utility of (68)Ga-DOTA-octreotate (DOTATATE) somatostatin receptor positron emission tomography (PET)/computed tomography (CT) imaging in the diagnosis of TIO. DESIGN AND SETTING A multicenter case series was conducted at tertiary referral hospitals. PATIENTS AND METHODS Six patients with TIO diagnosed between 2003 and 2012 in Australia were referred for DOTATATE PET imaging. We reviewed the clinical history, biochemistry, imaging characteristics, histopathology, and clinical outcome of each patient. RESULTS Each case demonstrated delayed diagnosis despite severe symptoms. DOTATATE PET/CT imaging demonstrated high uptake and localized the tumor with confidence in each case. After surgical excision, there was resolution of clinical symptoms and serum phosphate, except in one patient who demonstrated residual disease on PET/CT. All tumors demonstrated high somatostatin receptor subtype 2 cell surface receptor expression using immunohistochemistry. CONCLUSIONS In patients with TIO, DOTATATE PET/CT can successfully localize phosphaturic mesenchymal tumors and may be a practical first step in functional imaging for this disorder. Serum phosphate should be measured routinely in patients with unexplained muscle weakness, bone pain, or stress fractures to allow earlier diagnosis of TIO.
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Affiliation(s)
- Roderick J Clifton-Bligh
- Cancer Genetics Unit, Hormones and Cancer Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia
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Hu FK, Yuan F, Jiang CY, Lv DW, Mao BB, Zhang Q, Yuan ZQ, Wang Y. Tumor-induced osteomalacia with elevated fibroblast growth factor 23: a case of phosphaturic mesenchymal tumor mixed with connective tissue variants and review of the literature. CHINESE JOURNAL OF CANCER 2013; 30:794-804. [PMID: 22035861 PMCID: PMC4013303 DOI: 10.5732/cjc.011.10013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tumor-induced osteomalacia (TIO), or oncogenic osteomalacia (OOM), is a rare acquired Paraneoplastic disease characterized by renal phosphate wasting and hypophosphatemia. Recent evidence shows that tumor-overexpressed fibroblast growth factor 23 (FGF23) is responsible for the hypophosphatemia and osteomalacia. The tumors associated with TIO are usually phosphaturic mesenchymal tumor mixed connective tissue variants (PMTMCT). Surgical removal of the responsible tumors is clinically essential for the treatment of TIO. However, identifying the responsible tumors is often difficult. Here, we report a case of a TIO patient with elevated serum FGF23 levels suffering from bone pain and hypophosphatemia for more than three years. A tumor was finally located in first metacarpal bone by octreotide scintigraphy and she was cured by surgery. After complete excision of the tumor, serum FGF23 levels rapidly decreased, dropping to 54.7% of the preoperative level one hour after surgery and eventually to a little below normal. The patient's serum phosphate level rapidly improved and returned to normal level in four days. Accordingly, her clinical symptoms were greatly improved within one month after surgery. There was no sign of tumor recurrence during an 18-month period of follow-up. According to pathology, the tumor was originally diagnosed as “glomangioma” based upon a biopsy sample, “proliferative giant cell tumor of tendon sheath” based upon sections of tumor, and finally diagnosed as PMTMCT by consultation one year after surgery. In conclusion, although an extremely rare disease, clinicians and pathologists should be aware of the existence of TIO and PMTMCT, respectively.
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Affiliation(s)
- Fang-Ke Hu
- Orthopedic Department, Chinese PLA General Hospital, Beijing 100853, P. R. China
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33
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Jiang Y, Xia WB, Xing XP, Silva BC, Li M, Wang O, Zhang HB, Li F, Jing HL, Zhong DR, Jin J, Gao P, Zhou L, Qi F, Yu W, Bilezikian JP, Meng XW. Tumor-induced osteomalacia: an important cause of adult-onset hypophosphatemic osteomalacia in China: Report of 39 cases and review of the literature. J Bone Miner Res 2012; 27:1967-75. [PMID: 22532501 DOI: 10.1002/jbmr.1642] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Tumor-induced osteomalacia (TIO) is an acquired form of hypophosphatemia. Tumor resection leads to cure. We investigated the clinical characteristics of TIO, diagnostic methods, and course after tumor resection in Beijing, China, and compared them with 269 previous published reports of TIO. A total of 94 patients with adult-onset hypophosphatemic osteomalacia were seen over a 6-year period (January, 2004 to May, 2010) in Peking Union Medical College Hospital. After physical examination (PE), all patients underwent technetium-99m octreotide scintigraphy ((99) Tc(m) -OCT). Tumors were removed after localization. The results demonstrated that 46 of 94 hypophosphatemic osteomalacia patients had high uptake in (99) Tc(m) -OCT imaging. Forty of them underwent tumor resection with the TIO diagnosis established in 37 patients. In 2 patients, the tumor was discovered on PE but not by (99) Tc(m) -OCT. The gender distribution was equal (M/F = 19/20). Average age was 42 ± 14 years. In 35 patients (90%), the serum phosphorus concentration returned to normal in 5.5 ± 3.0 days after tumor resection. Most of the tumors (85%) were classified as phosphaturic mesenchymal tumor (PMT) or mixed connective tissue variant (PMTMCT). Recurrence of disease was suggested in 3 patients (9%). When combined with the 269 cases reported in the literature, the mean age and sex distribution were similar. The tumors were of bone (40%) and soft tissue (55%) origins, with 42% of the tumors being found in the lower extremities. In summary, TIO is an important cause of adult-onset hypophosphatemia in China. (99) Tc(m) -OCT imaging successfully localized the tumor in the overwhelming majority of patients. Successful removal of tumors leads to cure in most cases, but recurrence should be sought by long-term follow-up.
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Affiliation(s)
- Yan Jiang
- Department of Endocrinology, Key Laboratory of Chinese Health Ministry, Peking Union Medical College Hospital, Academy of Medical Science, Shuaifuyuan 1, Dong Cheng, Beijing, China
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Munoz J, Michel Ortega R, Celzo F, Donthireddy V. 'Tumour-induced osteomalacia'. BMJ Case Rep 2012; 2012:bcr.03.2012.5975. [PMID: 22736784 DOI: 10.1136/bcr.03.2012.5975] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 60-year-old man presented 2 years before his diagnosis with long-standing muscle cramping, progressive generalised weakness and chronic hip pain. The patient was found to have bilateral femoral neck pathologic fractures therefore, underwent reamed intramedullary nailing of both femurs. Laboratory studies showed hypophosphataemia. Bone marrow biopsy was negative for malignancy. Positron emission tomography demonstrated fludeoxyglucose uptake only in the posterior neck. Bone scan showed innumerable foci of increased activity throughout the skeleton consistent with pseudofractures seen in osteomalacia. Fine needle aspiration from the mass in the neck revealed a phosphaturic mesenchymal tumour of mixed connective tissue type. Resection of the mass in the neck resulted in resolution of generalised complaints with no evidence of recurrence with a follow-up of 12 months.
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Affiliation(s)
- Javier Munoz
- Department of Hematology and Oncology, Henry Ford Hospital, Detroit, Michigan, USA.
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35
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Markou A, Tsiama V, Tournis S, Papanastasiou L, Tsiavos V, Dassou A, Vlachou V, Papaliodi E, Asimaki N, Zografos G, Piaditis G. Coexistence of tumor-induced osteomalacia and primary hyperparathyroidism. Endocr Pract 2012; 17:e144-8. [PMID: 21940278 DOI: 10.4158/ep11177.cr] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present an unusual case of coexisting tumor-induced osteomalacia (TIO) and primary hyperparathyroidism (PHPT). METHODS We report the clinical features, imaging studies, and the results of laboratory investigations before and after surgical resection of both a soft-tissue tumor and a parathyroid adenoma. RESULTS A 44-year-old woman was referred to the endocrinology department with a diagnosis of PHPT accompanied by unusually severe hypophosphatemia, despite having received treatment with cinacalcet. Debilitating muscle weakness and bone pain, severe phosphaturia and hypophosphatemia, inappropriately normal calcitriol, and elevated fibroblast growth factor-23 and intact parathyroid hormone levels raised the suspicion of coexisting TIO and PHPT. Imaging studies were negative, but histologic characteristics of a palpable subcutaneous mass from the patient's thigh revealed a phosphaturic mesenchymal tumor. Complete remission after surgical removal of both the soft-tissue tumor and the parathyroid adenoma confirmed the diagnosis. CONCLUSION The coexistence of TIO and PHPT has not been described before and can cause life-threatening hypophosphatemia. Diagnosis and localization of the tumor is of paramount importance since surgery is the treatment of choice for both TIO and PHPT.
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Affiliation(s)
- Athina Markou
- Department of Endocrinology and Diabetes Center, G. Gennimatas Hospital, Athens, Greece.
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36
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Bergwitz C, Jüppner H. FGF23 and syndromes of abnormal renal phosphate handling. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 728:41-64. [PMID: 22396161 DOI: 10.1007/978-1-4614-0887-1_3] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Fibroblast growth factor 23 (FGF23) is part of a previously unrecognized hormonal bone-parathyroid-kidney axis, which is modulated by 1,25(OH)(2)-vitamin D (1,25(OH)(2)D), dietary and circulating phosphate and possibly PTH. FGF23 was discovered as the humoral factor in tumors that causes hypophosphatemia and osteomalacia and through the identification of a mutant form of FGF23 that leads to autosomal dominant hypophosphatemic rickets (ADHR), a rare genetic disorder. FGF23 appears to be mainly secreted by osteocytes where its expression is up-regulated by 1,25(OH)(2)D and probably by increased serum phosphate levels. Its synthesis and secretion is reduced through yet unknown mechanisms that involve the phosphate-regulating gene with homologies to endopeptidases on the X chromosome (PHEX), dentin matrix protein 1 (DMP1) and ecto-nucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1). Consequently, loss-of-function mutations in these genes underlie hypophosphatemic disorders that are either X-linked or autosomal recessive. Impaired O-glycosylation of FGF23 due to the lack of UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyl-transferase 3 (GALNT3) or due to certain homozygous FGF23 mutations results in reduced secretion of intact FGF23 and leads to familial hyperphosphatemic tumoral calcinosis. FGF23 acts through FGF-receptors and the coreceptor Klotho to reduce 1,25(OH)(2)D synthesis in the kidney and probably the synthesis of parathyroid hormone (PTH) by the parathyroid glands. It furthermore synergizes with PTH to increase renal phosphate excretion by reducing expression of the sodium-phosphate cotransporters NaPi-IIa and NaPi-IIc in the proximal tubules. Loss-of-function mutations in these two transporters lead to autosomal recessive Fanconi syndrome or to hereditary hypophosphatemic rickets with hypercalciuria, respectively.
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37
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Imel EA, Econs MJ. Approach to the hypophosphatemic patient. J Clin Endocrinol Metab 2012; 97:696-706. [PMID: 22392950 PMCID: PMC3319220 DOI: 10.1210/jc.2011-1319] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 11/02/2011] [Indexed: 12/13/2022]
Abstract
Hypophosphatemia is commonly missed due to nonspecific signs and symptoms, but it causes considerable morbidity and in some cases contributes to mortality. Three primary mechanisms of hypophosphatemia exist: increased renal excretion, decreased intestinal absorption, and shifts from the extracellular to intracellular compartments. Renal hypophosphatemia can be further divided into fibroblast growth factor 23-mediated or non-fibroblast growth factor 23-mediated causes. Proper diagnosis requires a thorough medication history, family history, physical examination, and assessment of renal tubular phosphate handling to identify the cause. During the past decade, our understanding of phosphate metabolism has grown greatly through the study of rare disorders of phosphate homeostasis. Treatment of hypophosphatemia depends on the underlying disorder and requires close biochemical monitoring. This article illustrates an approach to the hypophosphatemic patient and discusses normal phosphate metabolism.
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Affiliation(s)
- Erik A Imel
- Department of Medicine, Division of Endocrinology and Metabolism, Indiana University School of Medicine, 541 North Clinical Drive, CL 459, Indianapolis, Indiana 46202, USA
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38
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Chong WH, Yavuz S, Patel SM, Chen CC, Collins MT. The importance of whole body imaging in tumor-induced osteomalacia. J Clin Endocrinol Metab 2011; 96:3599-600. [PMID: 22143830 PMCID: PMC3232632 DOI: 10.1210/jc.2011-1757] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- William H Chong
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Radaideh ARM, Jaradat D, Abu-Kalaf MM, Nusier MK. Resolution of severe oncogenic hypophosphatemic osteomalacia after resection of a deeply located soft-tissue tumour. ACTA ACUST UNITED AC 2011; 16:87-90. [PMID: 19862367 PMCID: PMC2768508 DOI: 10.3747/co.v16i5.412] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Oncogenic osteomalacia is a rare metabolic bone disease characterized by phosphate leakage from the kidney and subsequent hypophosphatemia. It is caused by a phosphaturic factor produced by certain tumours. Removal of such tumours can completely cure the condition. Here, we report the case of a patient who was crippled with oncogenic osteomalacia. Extensive study revealed a tumour deeply located in the pelvis; removal of the tumour resulted in complete recovery. The tumour was identified as a mesenchymal tumour (mixed connective-tissue variant). The diagnostic evaluation, differential diagnosis, and treatment are discussed.
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Affiliation(s)
- A R M Radaideh
- Departments of Medicine, Prince Basma Teaching Hospital, Ministry of Health, Irbid, Jordan
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40
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Bergwitz C, Collins MT, Kamath RS, Rosenberg AE. Case records of the Massachusetts General Hospital. Case 33-2011. A 56-year-old man with hypophosphatemia. N Engl J Med 2011; 365:1625-35. [PMID: 22029985 PMCID: PMC4907641 DOI: 10.1056/nejmcpc1104567] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Clemens Bergwitz
- Division of Endocrinology, Massachusetts General Hospital, and Department of Medicine, Harvard Medical School, Boston, USA
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41
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Tournier A, Hanslik T, de la Faille R, Trad S, Baglin A, Prinseau J, Moulonguet-Doleris L. [Oncogenic osteomalacia: increased production of fibroblast growth factor 23 is not the unique actor]. Rev Med Interne 2011; 32:e99-e101. [PMID: 20943292 DOI: 10.1016/j.revmed.2010.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 09/14/2010] [Indexed: 10/19/2022]
Abstract
The importance of fibroblast growth factor 23 (FGF 23) has been highlighted in the mechanism of urinary leakage of phosphate in the oncogenic osteomalacia (OO). It is now a component of diagnosis of this disease. We report a 58-year-old man who presented with osteomalacia and hypophosphatemia secondary to urinary leakage of phosphorus. Although serum FGF 23 was normal, the diagnosis of OO was obtained after another cause of acquired prolonged hypophosphatemia has been excluded (hyperparathyroidism and Fanconi syndrome in particular). The search for a deep tumor was performed, allowing the detection of a 12 mm hemangiopericytoma in the upper thigh. Its removal allowed the rapid resolution of clinical symptoms and laboratory abnormalities. The importance of functional sequelae in OO depends on prompt diagnosis. Tumorectomy remains the optimal treatment. Thus, the search for a secreting tumor is essential even in the absence of elevated serum FGF 23.
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Affiliation(s)
- A Tournier
- Service de Médecine Interne et Néphrologie, Hôpital Ambroise-paré, Assistance Publique-Hôpitaux de Paris, 9, Avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
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42
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van der Rest C, Cavalier E, Kaux JF, Krzesinski JM, Hustinx R, Reginster JY, Delanaye P. Tumor-induced osteomalacia: The tumor may stay hidden! Clin Biochem 2011; 44:1264-6. [PMID: 21843522 DOI: 10.1016/j.clinbiochem.2011.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/07/2011] [Accepted: 07/19/2011] [Indexed: 01/07/2023]
Abstract
We report the case of a patient with severe muscular and articular tenderness that caused almost complete immobility. This subject had severe hypophosphatemia due to hyperphosphaturia. Fibroblast growth factor 23 (FGF-23) was abnormally high and the diagnostic of tumor-induced osteomalacia was made. Despite multiple tests, the tumor was not localized. In this report, we discuss different possible investigations to localize the tumor. Lastly, we review the potential therapy available when tumor is not found and can thus not be excised.
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Abstract
Tumor-induced osteomalacia (TIO) is a rare and fascinating paraneoplastic syndrome in which patients present with bone pain, fractures, and muscle weakness. The cause is high blood levels of the recently identified phosphate and vitamin D-regulating hormone, fibroblast growth factor 23 (FGF23). In TIO, FGF23 is secreted by mesenchymal tumors that are usually benign, but are typically very small and difficult to locate. FGF23 acts primarily at the renal tubule and impairs phosphate reabsorption and 1α-hydroxylation of 25-hydroxyvitamin D, leading to hypophosphatemia and low levels of 1,25-dihydroxy vitamin D. A step-wise approach utilizing functional imaging (F-18 fluorodeoxyglucose positron emission tomography and octreotide scintigraphy) followed by anatomical imaging (computed tomography and/or magnetic resonance imaging), and, if needed, selective venous sampling with measurement of FGF23 is usually successful in locating the tumors. For tumors that cannot be located, medical treatment with phosphate supplements and active vitamin D (calcitriol or alphacalcidiol) is usually successful; however, the medical regimen can be cumbersome and associated with complications. This review summarizes the current understanding of the pathophysiology of the disease and provides guidance in evaluating and treating these patients. Novel imaging modalities and medical treatments, which hold promise for the future, are also reviewed.
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Affiliation(s)
- William H Chong
- Skeletal Clinical Studies Unit, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, Hatfield Clinical Research Center, National Institutes of Health, Bethesda, Maryland 20892, USA
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44
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Abstract
Tumor-induced osteomalacia (TIO) is an acquired disorder of isolated renal phosphate wasting associated with tumors, typically of mesenchymal origin. Patients with TIO share similar biochemical and skeletal phenotypes with patients who have autosomal dominant hypophosphatemic rickets (ADHR) and X-linked hypophosphatemia. The study of TIO introduced the idea of the existence of circulating factors, referred to as 'phosphatonins', produced by the tumor, which act upon the kidney to reduce phosphate reabsorption. Although several factors have been identified, the phosphatonin FGF-23, also identified as the causative factor in ADHR, is currently the best characterized of these factors relative to phosphate handling. This review describes the importance of TIO in understanding phosphate homeostasis in the context of new endocrine interactions between the skeleton and the kidney.
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Affiliation(s)
- Emily G Farrow
- Department of Medical & Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth E White
- Author for correspondence: Department of Medical & Molecular Genetics, Indiana University School of Medicine, 975 West Walnut Street, IB130, Indianapolis, IN 46202, USA, Tel.: +1 317 278 1775, Fax: +1 317 274 2293,
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45
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46
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Bergwitz C, Jüppner H. Disorders of phosphate homeostasis and tissue mineralisation. ENDOCRINE DEVELOPMENT 2009; 16:133-56. [PMID: 19494665 PMCID: PMC3810012 DOI: 10.1159/000223693] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Phosphate is absorbed from the diet in the gut, stored as hydroxyapatite in the skeleton, and excreted with the urine. The balance between these compartments determines the circulating phosphate concentration. Fibroblast growth factor 23 (FGF23) has recently been discovered and is part of a previously unrecognised hormonal bone-kidney axis. Phosphate-regulating gene with homologies to endopeptidases on the X chromosome, and dentin matrix protein 1 regulate the expression of FGF23 in osteocytes, which then is O-glycosylated by UDP-N-acetyl-alpha-D-galactosamine: polypeptide N-acetylgalactosaminyl-transferase 3 and secreted into the circulation. FGF23 binds with high affinity to fibroblast growth factor receptor 1c in the presence of its co-receptor Klotho. It inhibits, either directly or indirectly, reabsorption of phosphate and the synthesis of 1,25-dihydroxy-vitamin-D by the renal proximal tubule and the secretion of parathyroid hormone by the parathyroid glands. Acquired or inborn errors affecting this newly discovered hormonal system can lead to abnormal phosphate homeostasis and/or tissue mineralisation. This chapter will provide an update on the current knowledge of the pathophysiology, the clinical presentation, diagnostic evaluation and therapy of the disorders of phosphate homeostasis and tissue mineralisation.
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Affiliation(s)
- Clemens Bergwitz
- Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA.
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47
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Duet M, Kerkeni S, Sfar R, Bazille C, Lioté F, Orcel P. Clinical impact of somatostatin receptor scintigraphy in the management of tumor-induced osteomalacia. Clin Nucl Med 2008; 33:752-6. [PMID: 18936605 DOI: 10.1097/rlu.0b013e31818866bf] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Tumor-induced osteomalacia (TIO) is a rare condition due to phosphate wasting secondary to the release of a phosphatonin, fibroblast growth factor-23. Attempts to identify the tumor by physical examination and/or conventional imaging are sometimes unrewarding. In such cases, somatostatin receptor scintigraphy with octreotide has been successfully proposed. METHODS Two case reports and a review of the literature allow to demonstrate the diagnostic usefulness of octreotide and the therapeutic value of somatostatin. RESULTS Octreotide studies were positive in 79% of 24 reported TIO, including our 2 cases. In one of our patients with incomplete removal of the tumor, octreotide therapy was unable to improve hypophosphatemia, despite a decrease in fibroblast growth factor-23 levels by 30%. Similar results were achieved in most of the reported cases. Surgical procedures were effective in these cases and resulted in complete clinical and biochemical recovery. CONCLUSION We highlight the impact of somatostatin receptor evaluation in the management of TIO.
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Affiliation(s)
- Michèle Duet
- Department of Nuclear Medicine, Hôpital Lariboisière, APHP, Paris, University Paris 7 Denis-Diderot, Paris, France.
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48
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Biagini GLK, Coutinho PR, Jonasson TH, Ueda CE, Gama RR. Osteomalácia oncogênica: cintilografia com sestamibi-99mTc na localização do tumor. ACTA ACUST UNITED AC 2008; 52:1505-9. [DOI: 10.1590/s0004-27302008000900016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2008] [Accepted: 09/11/2008] [Indexed: 02/03/2023]
Abstract
A osteomalácia oncogênica hipofosfatêmica (OOH) é uma síndrome paraneoplásica induzida por tumor, de tecidos mole ou ósseo. Apresenta-se com dor e fraturas, acompanhada de hipofosfatemia, hiperfosfatúria e concentrações plasmáticas de 1,25(OH)2D3 inapropriadamente normais/diminuídas. Após a remoção do tumor, a completa resolução das anormalidades clínicas e bioquímicas é sua maior característica. Uma mulher de 44 anos de idade é descrita no caso com dificuldade para caminhar por causa de dores nos membros inferiores, fraqueza muscular generalizada e hipofosfatemia com relativa hiperfosfatúria. A cintilografia de corpo total com sestamibi-99mTc mostrou acúmulo do radiofármaco no terço superior de coxa esquerda onde pequeno tumor foi detectado no exame pelo ultra-som. Com a retirada do tumor, um lipoma, os sintomas melhoraram após um mês, com recuperação completa ao redor do quarto mês. Neste caso, a cintilografia de corpo inteiro com sestamibi-99mTc foi decisiva na localização do tumor causador da osteomalácia oncogênica.
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Abstract
Although relatively uncommon individually, the various causes of hypophosphataemic rickets have provided an impetus for unravelling the mechanisms of phosphate homeostasis and bone mineralisation. Over the past 10 years, considerable advances have been made in establishing the gene mutations responsible for a number of the inherited causes and in understanding the mechanisms responsible for tumour-induced osteomalacia/rickets. The most exciting aspects of these discoveries have been the discovery of a whole new class of hormones or phosphatonins which are thought to control phosphate homoeostasis and 1 alpha-hydroxylase activity in the kidney, through a bone-kidney-intestinal tract axis. Although our understanding of the interrelationships is far from complete, it raises the possibilities of improved therapeutic agents in the long-term, and has resulted in improved diagnostic abilities in the short-term.
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Affiliation(s)
- John M Pettifor
- MRC Mineral Metabolism Research Unit, Department of Paediatrics, Chris Hani Baragwanath Hospital, University of the Witwatersrand, PO Bertsham 2013, Johannesburg, South Africa.
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50
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(68)Ga-DOTANOC PET/CT for the detection of a mesenchymal tumor causing oncogenic osteomalacia. Eur J Nucl Med Mol Imaging 2008; 35:1034. [PMID: 18369618 DOI: 10.1007/s00259-008-0755-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Accepted: 02/19/2008] [Indexed: 10/22/2022]
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